What is the management for a patient with a subconjunctival hemorrhage?

Management of Subconjunctival Hemorrhage

Subconjunctival hemorrhage requires no specific treatment in most cases and will resolve spontaneously within 1-2 weeks without intervention. The management focuses on patient reassurance and addressing any underlying causes.

Diagnostic Assessment

When evaluating a patient with subconjunctival hemorrhage, consider:

• Location and extent of hemorrhage (inferior areas are more commonly affected than superior areas) 1
• History of trauma or contact lens use (common causes in younger patients) 2
• Presence of systemic vascular diseases (hypertension, diabetes, arteriosclerosis - common in elderly) 2
• Medication history, particularly anticoagulants like warfarin 3
• Recurrence pattern (single episode vs. multiple episodes)

Management Algorithm

1. First-Line Management

• Patient reassurance that the condition is benign and self-limiting
• Artificial tears for mild irritation or discomfort
• Cold compresses for the first 24-48 hours to reduce discomfort
• Discontinue contact lens wear temporarily if applicable

2. Evaluation of Underlying Causes

• Check blood pressure particularly in older patients 4
• Review medications that may contribute to bleeding risk
• Consider bleeding disorders if recurrent or extensive hemorrhage

3. Special Considerations

For traumatic subconjunctival hemorrhage:

• Typically presents as localized hemorrhage in temporal areas 1
• Evaluate for other ocular injuries
• Smaller extent compared to non-traumatic causes 1

For recurrent or persistent subconjunctival hemorrhage:

• Workup for systemic hypertension
• Evaluation for bleeding disorders
• Assessment for systemic and ocular malignancies
• Review of medication side effects 2

When to Refer to an Ophthalmologist

Immediate referral is warranted if:

• Subconjunctival hemorrhage is associated with vision changes
• There is significant pain (beyond mild irritation)
• Hemorrhage is extensive or recurrent
• There is associated trauma with potential for other ocular injuries

Follow-up Recommendations

• Most cases require no follow-up if isolated and non-recurrent
• For recurrent cases, follow-up within 1-2 weeks to assess resolution and evaluate for underlying causes
• Patients on anticoagulants with recurrent hemorrhages should have their anticoagulation status evaluated 3

Patient Education

Advise patients that:

• Subconjunctival hemorrhage typically resolves within 1-2 weeks
• The blood may appear to spread before it resolves
• Color changes (from bright red to yellow) are normal during healing
• Avoid rubbing the eyes and activities that might increase ocular pressure
• Return if symptoms worsen or new symptoms develop

Pitfalls and Caveats

• Don't overlook subconjunctival hemorrhage as a potential first sign of serious systemic disorders like idiopathic thrombocytopenic purpura 5
• In patients with hypertension, diabetes, or hyperlipidemia, subconjunctival hemorrhage tends to be more extensive 1
• The event rate of subconjunctival hemorrhage in patients on warfarin is relatively low (0.35%), but medication changes in the preceding month may be a contributing factor 3

Remember that while subconjunctival hemorrhage appears dramatic and concerning to patients, it is typically benign and self-limiting, requiring only reassurance and monitoring in most cases.